Intake Form
Please print this page and bring it to your first session along with a signed copy of the policies on the previous page. If you have a medical referral you can text a photo to me or bring it along with your copies of the policies and Client Intake forms.
Client Consent and Questionnaire
Name_______________________________________________________________________________
Address _____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Best phone number____________________________________
Best email ___________________________________________
Name of emergency contact: ______________________________________
Their phone ___________________________ email ________________
Relationship: ____________________________________________
Do they live with you? Yes_______ NO__________
Briefly describe the reason for your visit.____________________________________________
____________________________________________________________________________
____________________________________________________________________________
How long have you had this discomfort or situation ______________
Do you have a doctor or chiropractor’s referral for medical massage? yes______ no______
How did you find me? _______________________________________
Do you have any ongoing health issues, such as diabetes, heart disease, depression for which you take medication?
Please list:__________________________________________________________________________
Covid-19 Related Questions
1.Have you been asked to self-isolate or quarantine by a doctor or a local public health official in the last 14 days?
2. Have you been tested for COVID-19? NA______ If so, when? _____ /____/____
a. What was the result? Positive_____ Negative______
3. In the last 14 days:
-
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath, or other respiratory problems, new, or strange symptoms)?
-
Yes______ No______
If yes, please describe___________________________________________________
4. I'm fully vaccinated. Are you fully vaccinated against COVID-19? Yes_______ No_______
1. If not, are you partially vaccinated? Yes______ No______
2. If not, do you plan to do so? Yes_____ No______
5. Have you had close contact with or cared for someone diagnosed with COVID-19, or someone exhibiting cold or flu-like symptoms? Yes______ No______
6. Have you been tested for COVID-19?
a. if so, when ______/______/_____
b. What was the result? positive _______ negative_____
7. Have you been somewhere with a high infection rate in the last 2 weeks? Yes_______ No______
8. Have you been to any unmasked gatherings, such as political rallies, beaches, schools, or parties in the last 14 days? Yes_____ No_____
9. I have seen the policies under "Other" on this site and I agree to abide by them. Yes_______ No_______
For everyone’s well-being:
I acknowledge that while precautions are taken for my safety, any bodywork, or in-person meeting carries inherent risks. By coming to an appointment I am accepting these risks. Yes_______ No_______
Should any answers to the previous questions change, I agree to inform Ms. Peltier immediately. Yes____ No___
Furthermore, if I have a temperature above 100.2°F on the day of the appointment, or have developed cold or flu-like symptoms since scheduling the appointment, I agree to inform Ms. Peltier and postpone my session?
Yes_______ No _______
I also agree that should I fail to inform Ms. Peltier of any changes to my health prior to my appointment, or I have a temperature of 100 degrees or more upon arrival, she has the right to refuse service.
Yes________ No__________
I agree to these conditions and affirm the truth of my statements: Yes______
Signature: __________________________________________________________
Date___________